Clinical Vignettes 101

Physicians are exposed to a wide variety of cases that pique our interest. Cases that make you go home and read just a little bit more. Cases that prompt you to seek out your classmates and colleagues for further discussion, or trigger a call to someone from your past. Residents and students often ask, “Should I write this case up?” Our answer is, “Yes!”

Why do we recommend that you write the case up? Much of medical education is a clinical- or case-based exercise. Clinical cases provide context for the principles being taught. We use real cases to point out the nuance in a presentation of a particular illness or the management of a disease.

In clinical conferences, such as morning report or clinical-pathologic conferences (CPCs), we highlight the choices we make as physicians to provide the best care. Respected physicians and master clinicians at our own institutions often lead these discussions, which form the building blocks for how many of us will practice in our careers.

At grand rounds, the best speakers start with a case. These vignettes grab our attention, making us realize the importance of what the speaker teaches us.

The point of these vignettes is to help you develop skills as an author and academician. Since most meetings do not provide any feedback on the review of your submission, outside of “accepted” or “rejected,” it is important to get this from your own institution.

Writing up a vignette will give you a skill set you need. You learn how to select a case, create a “teachable moment,” or hone a series of teaching points. You develop your skills in searching and critically appraising the literature. You become a content expert among your peers. This activity helps you to develop and master the academic skills that will drive your career and will be pivotal in your success.

Step 1

Be a good doctor and make the correct diagnosis: Interesting cases will come to you. Don’t chase a zebra on every cough. Don’t send autoimmune panels for every rash. Read about each patient’s case that you see. Use the time to build your clinical acumen and develop your own illness scripts. Through the process of being a thoughtful student of medicine, you will come to distinguish the fascinoma from the merely fleeting infatuation with a diagnosis.

Step 2

Recognize the good case: The best way to recognize a good case is appreciate when it excites people locally. If you present it at morning report or CPC, are you inundated with requests to speak more after the conference has finished? Did it stump your colleagues (usually a pretty bright group)? Do you find that the consultants ask for others in their division to come and see the case? Clinically, did it take the team a while to come to the end diagnosis? If any of these are true, then you should move forward.

Step 3

Perform a literature search: How often does a similar situation arise? Is it 1 in 10,000, 1 in a million, or less? Even a case of 1 in 10,000 can be impactful to read about when you consider how long it may take a physician to see that many patients.

Step 4.

Develop two or three teaching points: Most abstracts for national and regional meetings have a restrictive word limit. When you consider all the information required of a thorough case presentation and adequate discussion, it can seem almost impossible to fit it all in. Start early, at least a month before the deadline if you can, and start big. Determine two or three key teaching points you wish to make. These will serve as your roadmap for the write-up.

Next, write down everything you want to say. Then cut the verbiage and descriptions that are not needed to tell your story. Focus on two or three take-home points. Each fact included or statement made should help to guide the reader to these lessons. As readers and authors, we also like to see prevalence and incidence of disease findings, or how good a test is with specificity and sensitivity values. Make sure the readers know what you want them to learn.

click for large version

click for large version

Step 5

Keep the case concise, and focus on the discussion: The best write-ups keep the case description short and focused. Avoid trying to tell your readers everything about your case. Highlight what makes your case different without including extraneous information that does not support your teaching points. This leaves more room to focus on your discussion and explain to the reader the importance of your case. The discussion is where you create the “teachable moment” by elaborating on your teaching points.

Step 6

Keep your drafts and proofread your work carefully: The process of writing a clear and concise vignette will take many drafts. To do a great job, plan for at least three or four versions. Through the process of revisiting every word you use, you will start to hone your mastery of the topic; you will see the case in a new way with each draft.

As you do this, keep each edit as a separate file. You will inevitably edit something out early on that you will want to put back in later. Keeping your drafts will make this much easier.

At the final version, proofread carefully! Most reviewers will deduct points for poor grammar and misspellings. If it looks sloppy, then a reader will assume it represents sloppy thoughts.

Submit Today

HM14 abstracts are being accepted for SHM’s scientific poster and oral abstract competition, known as Research, Innovations, and Clinical Vignettes (RIV), until Dec. 1. Visit the “Academic Community Page” at www.hospitalmedicine.org for a full suite of resources for submitting your abstract, or go directly to www.hospitalmedicine2014.org to submit your abstract today.

Step 7

Get feedback: Have others read your work. It is always hard to put your writing out there for critique, particularly when it is such a personal representation of your own clinical thought. Hopefully, you have collaborated with others involved in the case; however, to avoid any “group think” about the work, it is best to have uninvolved individuals (e.g., trusted faculty member, program director, division chief) review your work before submission. The point of these vignettes is to help you develop skills as an author and academician. Since most meetings do not provide any feedback on the review of your submission, outside of “accepted” or “rejected,” it is important to get this from your own institution. It will also heighten your chances of acceptance. Take their suggestions openly, and use them to refine your abstract.

Step 8

Consider the following keys to a poster or oral presentation: The presentation at the meeting should be an expansion on the abstract. Remember, you have described the situation, but now you have the opportunity to use a picture. The old adage that a picture is worth a thousand words really rings true here.

Avoid copying and pasting your text. Concise statements will grab people’s eyes and leave you more space for charts and images. Visuals grab the reader’s eye better than small-font text.

Conclusion

Your first clinical vignette can be a truly great experience. Although it is a lot of hard work, presenting clinical thought is a skill that you must learn. Once you do this, you might find that you have “caught the bug,” and will find yourself well on your way to a role in medical education. You might even start a larger project based on this experience.

Dr. Burger is associate program director of internal medicine residency in the Department of Medicine at Beth Israel Medical Center and assistant dean and assistant professor of medicine at Albert Einstein College of Medicine, both in New York City. Dr. Paesch is a comprehensive care physician in the section of hospital medicine at the University of Chicago, and assistant professor at the University of Chicago Pritzker School of Medicine. Dr. Miller is director of student programs, associate program director, residency, and associate professor of medicine in the Department of Medicine at Tulane Health Sciences Center in New Orleans.